Set the Cuboid and Fix the Foot: A 6 Step Foot and Ankle Mobilization Series
There are a number of subjective complaints and clinical observations that originate in the foot and ankle. A wide host of things are capable of disrupting the normal anatomical alignment and arthrokinematics of the foot and ankle and causing pain. Restoring appropriate biomechanics at the foot and ankle is a critical first step in moving patients towards pain relief and restoration of function.
The following assessment and treatment series, when applied based on both the specific findings of a comprehensive physical evaluation and the understanding of appropriate contraindications, has been extremely successful in restoring foot and ankle arthrokinematics in the clinical setting. It has been successfully applied to resolve instances of chronic cuboid syndrome, plantar fasciitis, morton’s neuroma, tarsal tunnel syndrome, posterior tibialis tendonitis and …….?
The intended purpose of this article is to encourage the practitioner to consider potential alternatives to current treatment paradigms. The treatment techniques utilized in each step in this series may vary but typically include muscle energy techniques and joint mobilization and/or manipulation where appropriate. The practitioner is encouraged to seek additional training in these techniques as needed. (You can eventually link to your coursework. For now, reference MET, Mitchell or other sources? Do you have books where I can reference the technique that you use in each of the 6 steps)
Reset the foot and ankle in 6 Steps
First, assess the fibula for its overall position by completing a bilateral comparison being sure to note superior/inferior glide as well as internal/external rotation. Inversion ankle sprains often result in a fibula that is displaced inferiorly and stuck in internal rotation.
Do you want to go into details for each step? something like this: For an inferior and internally rotated fibula (common with inversion ankle sprains), mobilize the fibula using the heel of your hand to glide the lateral malleoli superiorly and into external rotation. A palpable click will often accompany a successful mobilization.
Another successful technique uses muscle energy. Place the client in prone with the knee flexed and the great toe resting on your shoulder. Manually glide the fibula superiorly and externally while recruiting the extensor hallicus longus against your shoulder and the hamstring. (Reference MET?)
Second, assess the talus for mobility being sure to include torsion in your assessment. Restrictions at this joint respond nicely to manipulation when no contraindications for this technique are present.
Third, assess the subtalar joint isolating all three facets; posterior, middle and anterior. Assess the facets for mobility being sure to differentiate between the various ligaments. If ligamentous laxity is present, friction techniques to the the affected ligament will often restore subtalar joint motion. If pure articular restriction is present, manipulation or muscle energy techniques may be applied. In those clients who present with increased foot pronation, the spring ligament (navicular-calcaneal) often demonstrates laxity. Also, check for possible rupture of the posterior talocalcaneal ligament and/or the medial talocalcaneal ligament.
Fourth, assess the mobility of the navicular. If navicular mobility is limited, distract the metatarsal rays to gap the cuneiforms prior mobilizing the navicular. If you are unsuccessful in restoring the mobility to the navicular, recheck steps 1-3 as there is likely a restriction that has not been fully cleared.
Fifth, assess the mobility of the cuneiforms and mobilize as needed. An elevated middle cuneiform is commonly seen in soccer players.
Sixth, palpate and assess the position and mobility of the cuboid. The cuboid is often dropped following inversion ankle sprains and will be tender to palpation on the plantar surface of the foot. Mobilizing the cuboid, as needed, often completes a structural reset at the foot and ankle.
If the cuboid has been displaced, a taping technique should be utilized for a few weeks to help maintain alignment and give the affected ligaments a chance to heal. (Create a video on cuboid taping and then we can link it here)
Do you want to mention orthotics here? I think that could be an entire article unto itself.
Neuromuscular reeducation in the form of single leg balancing or other closed kinetic chain and proprioceptive activities are appropriate following treatment to help restore proper function.
Currently 700 words, including the areas in red.